| USA Order Form for CP Pharmaceuticals |
| ***Note*** The address for delivery must be the same address that is on your USDA Import Permit. Your insulin must be sent to the address on your import permit. |
| USA ORDER FORM FOR CP PHARMACEUTICALS BEEF INSULIN (one of 4 FDA required documents) |
| PRODUCT |
| QUANTITY (please indicate) |
| COST |
| TOTAL (please calculate) |
| Hypurin® Bovine Neutral 100iu 10ml vial |
| ______ |
| £25.00 |
| £_________ |
| Hypurin® Bovine Isophane 100iu 10ml vial |
| ______ |
| £25.00 |
| £_________ |
| Hypurin® Bovine Lente 100iu 10ml vial |
| ______ |
| £25.00 |
| £_________ |
| Hypurin® Bovine Protamine Zinc 100iu 10ml vial |
| ______ |
| £25.00 |
| £_________ |
| +Courier Cost (2 day service) |
| 1 |
| £58.00 |
| £58.00 |
| TOTAL AMOUNT PAYABLE |
| £________ |
| PAYMENT (Please tick choice) |
| A) By Credit Card |
| Please charge my: |
| 1. Visa |
| 2. Mastercard |
| 3. Access |
| 4. Eurocard |
| Card Number |
| __ |
| __ |
| __ |
| __ |
| __ |
| __ |
| __ |
| __ |
| __ |
| __ |
| __ |
| __ |
| __ |
| __ |
| __ |
| __ |
| Expiry Date: ___ ___/___ ___ |
| I authorise you to debit my credit Account with the above amount. |
| Signed ________________________________________________ |
| Date ___ ___/___ ___/___ ___ ___ ___ |
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| B) By Banker's Draft |
| I enclose a Banker's Draft in Pounds Sterling payable to CP Pharmaceuticals Ltd |
| DELIVERY DETAILS |
| These details are extremely important, as the insulin will need to be refrigerated immediately upon receipt. |
| Delivery Address: |
| _____________________________________________________________ |
| _____________________________________________________________ |
| _____________________________________________________________ |
| _____________________________________________________________ |
| Contact Name:___________________________________ |
| Telephone Number:__________________________ |
| Fax Number: __________________________ |
| Please return this form (fax or post) with the three documents mentioned overleaf to: |
| Export Department Wockhardt UK Ltd Ash Road North Wrexham Industrial Estate Wrexham, LL13 9UF United Kingdom |
| Telephone Number: + 44 1978 669221 Fax Number: + 44 1978 669230 |
| INDEX |
| Home Page |
| Other Important Links |
| How to Import Beef Insulin into the US |
| Dr.'s Letter of Medical Necessity |
| Your Statement Letter to the FDA. |
| Import Permit Application |
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| ___________________________________________________________________________________________________________ |
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| This form may be copied and pasted into Word, filled out, saved as a file and either Faxed or mailed to CP Pharmaceuticals or you can get a copy by emailing CP at: export@wockhardt.co.uk . You may also email your documents if you make special arrangements with CP Pharmaceuticals. With your order you must have an import permit, your doctors letter of medical necessity and your letter to the FDA stating that the beef insulin is for your personal use and is for a 6 month supply or less. **Do not confuse the Application for an import permit with the actual USDA permit.** See import permit application page.** |
| Name of card holder (as it appears on the card):_________________________________________ Address of card holder:_________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ |
| USA Pages |
| Main Index |
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| Questions? Email us. Double click on the email globe. |
| Check one |
| *Administration Fee 1 |
| £50.00 |
| £50.00 |